Diabetic Patient Drop Off Form

Thank you for trusting us with your pet’s care. We understand that managing diabetes can be challenging, and we are here to support both you and your furry family member every step of the way. Rest assured, our team is dedicated to providing gentle, attentive, and expert care to ensure their health and comfort.

If you have any questions or special instructions, please let us know—we’re honored to be part of your pet’s journey to wellness. ❤️

"*" indicates required fields

Name*

First Last

Email*

Patient Name*

Phone*

Species*

Dog

Cat

Exotic

If exotic:*

Sex*

Male

Neutered Male

Female

Spayed Female

At what number can you be contacted at day of drop off?*

Authorization and Risk Assessment. Please initial after each statement.

What type of food does your pet eat:*

What time(s) of day do you feed your pet?*

Amount Fed:*

Was your pet fed today?*

Yes

No

If yes, what time?*

Did your pet eat?*

Ate well

Ate half

Ate a little

Didn’t eat

Does your pet receive any snacks?*

Yes

No

If yes, please list what type, the amount, and when they are given below:*

Is water given?*

Free choice

Controlled

If controlled, how much?*

Type of insulin you are giving:*

What time(s) of day do you administer insulin?*

Amount:*

Did your pet receive insulin this morning?*

Yes

No

What time and amount was given?*

Since your last visit, your pet’s appetite has been:*

Normal

Increased

Decreased

Since your last visit, has your pet’s water intake:*

Normal

Increased

Decreased

Since your last visit, has your pet exhibited any increase in urination?*

Yes

No

If yes, is he/she straining to urinate?*

Yes

No

If yes, is there any discoloration or blood in the urine:*

Yes

No

If yes, describe:*

Are you noticing any new or abnormal behaviors?*

Yes

No

If yes, describe:*

Do you have any other concerns?*

Yes

No

If yes, describe:*

Is your pet on any other medications aside from insulin:*

Will you need a refill of insulin today?*

Yes

No

Please tell us anything else you think may help us treat and/or help regulate your pet’s diabetes.*

I understand that I will assume financial responsibility for all services rendered at the time of discharge.*

Please select the one of the following:*

CPR- I authorize appropriate life saving measures. I understand and assume all financial responsibility for these additional fees that are not included in your treatment plan.

DNR- I do not wish for life saving measures to be performed. I am electing “DO NOT RESUSCITATE” status for my pet.

Date*

MM slash DD slash YYYY

Signature*

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